MEDICARE: LESLIE FERNANDA JIMENEZ TERRAZAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1255947735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE FERNANDA JIMENEZ TERRAZAS

Provider Business Mailing Address
First Line	:	5213 W VERNON AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85035-1950
Country	:	US
Telephone Number	:	602-904-9185
Fax Number	:

Provider Business Practice Location Address
First Line	:	5213 W VERNON AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85035-1950
Country	:	US
Telephone Number	:	602-904-9185
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2020
Last Update Date	:	09/19/2020

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